Induction of apoptosis by capsaicin in hepatocellular cancer cell line SMMC-7721 is mediated through ROS generation and activation of JNK and p38 MAPK pathways

Capsaicin, one of the major pungent ingredients found in red peppers, has been shown to have anti-carcinogenic effect on various cancer cells through multiple mechanisms. In this study, we investigated the apoptotic effect of capsaicin on human hepatocellular cancer cell line SMMC-7721, as well as the possible mechanisms involved. Treatment of SMMC-7721 cells with capsaicin resulted in a dose-dependent inhibition of cell-viability and induction of apoptosis which was associated with the generation of ROS and persistent disruption of mitochondrial membrane potential. These effects were significantly blocked when cells were pretreated with a general antioxidant N-acetyl cysteine (NAC). We also found that capsaicin induced JNK and p38 MAPK phosphorylation. JNK and p38 MAPK inhibitor effectively blocked capsaicin-induced SMMC-7721 cell apoptosis. In addition, NAC completely blocked phosphorylation of JNK and p38 MAPK induced by capsaicin. Our results indicate that capsaicin induced in SMMC-7721 cell apoptosis through generation of intracellular ROS and activation of JNK and p38 MAPK pathways.

An indeterminate nodule in the cirrhotic liver discovered by surveillance imaging is a prelude to malignancy

BACKGROUND

Surveillance imaging often shows indeterminate lesions in the cirrhotic liver, which may represent early hepatocellular carcinoma (HCC), dysplastic or regenerative nodules, or vascular shunts. The risk of HCC after identification of an indeterminate nodule is not well described.

METHODS

We identified 252 patients with cirrhosis and at least one indeterminate nodule discovered on surveillance imaging over a 4-year period. The incidence of HCC development within 2 years of nodule identification was measured along with baseline risk factors associated with developing HCC.

RESULTS

The incidence of HCC in this population was 21% (53 of 252), and risk factors associated with HCC included chronic viral hepatitis, male gender, and low platelet count. The median time from identification of an indeterminate nodule to diagnosis of HCC was 2.7 months. Patients with indeterminate nodules who developed HCC were more likely have to have an indeterminate nodule with arterial enhancement.

CONCLUSIONS

The 2-year incidence of HCC in the setting of cirrhosis and an indeterminate nodule discovered by surveillance imaging may be as high as one in five persons. Early follow-up imaging, biopsy, or empiric treatment should be considered for those at higher risk. Further, this population is well suited for early detection biomarker and chemoprevention studies.

Long noncoding RNA in liver diseases

The identification of the presence of large RNA transcripts that do not code for proteins but that may have biological functions has provided an important new perspective in gene regulation. These long noncoding RNAs (lncRNAs) are being increasingly recognized to contribute to many biological processes through diverse mechanisms. The roles of these emerging genes are being recognized across kingdoms. These findings are profoundly altering our understanding of disease pathobiology and leading to the emergence of new biological concepts underlying human diseases. Strategies for the discovery and characterization of lncRNAs are highlighted. Several lncRNAs have been described in liver disease, and in liver cancers in particular. Their molecular mechanisms of action, function, and contributions to disease pathophysiology are reviewed. LncRNA genes associated with liver diseases have potential roles as biomarkers of disease diagnosis, prognosis, or therapeutic response as well as direct targets for therapeutic intervention.

CONCLUSION

The emerging knowledge in this rapidly advancing field offers promise for new fundamental knowledge and clinical applications that will be relevant for human liver diseases.

Statin treatment reduces the risk of hepatocellular carcinoma but not colon cancer-results from a nationwide case-control study in Sweden

BACKGROUND

Several studies have indicated that statins may have anticarcinogenic effects. The aim of the present study was to investigate if statin treatment was associated with a reduced risk of hepatocellular carcinoma (HCC) or colon cancer.

METHODS

A nationwide case-control study was carried out in which all cases of HCC and colon cancer in the Swedish population above 40 years of age between 1 July 2006 and 31 December 2010 were identified in the Swedish Cancer Register. For every case, five controls were selected and matched on age and sex. Data on statin use was extracted from the Swedish Prescribed Drug Register. We estimated risks using conditional logistic regression and adjusted for educational level, concomitant medications and comorbidity.

RESULTS

Identified were 3994 cases of HCC and matched with 19.970 controls, and 21.143 cases of colon cancer were identified and matched with 105.715 controls. In the adjusted analysis, the odds ratio (OR) for HCC among statin users was 0.88 (95% confidence interval (CI) 0.81-0.96), and the OR for colon cancer was 1.04 (95%CI 1.00-1.08) compared with non-users.

CONCLUSION

Statin use was associated with a modest decreased risk of HCC but did not influence the risk of colon cancer. Future randomized placebo-controlled trials in HCC high-risk patients are warranted to further investigate the possible prophylactic effect of statins in HCC.

Emerging molecular targets in oncology: clinical potential of MET/hepatocyte growth-factor inhibitors

The MET/hepatocyte growth-factor (HGF) signaling pathway plays a key role in the processes of embryogenesis, wound healing, and organ regeneration. Aberrant activation of MET/HGF occurs through multiple mechanisms including gene amplification, mutation, protein overexpression, and abnormal gene splicing interrupting autocrine and paracrine regulatory feedback mechanisms. In many cancers including non-small-cell lung cancer, colorectal, gastric, renal, and hepatocellular cancer, dysregulation of MET may lead to a more aggressive cancer phenotype and may be a negative prognostic indicator. Successful therapeutic targeting of the MET/HGF pathway has been achieved using monoclonal antibodies against the MET receptor and its ligand HGF in addition to MET-specific and multitargeted small-molecule tyrosine-kinase inhibitors with several drugs in late-phase clinical trials including onartuzumab, rilotumumab, tivantinib, and cabozantinib. MET frequently interacts with other key oncogenic tyrosine kinases including epidermal growth-factor receptor (EGFR) and HER-3 and these interactions may be responsible for resistance to anti-EGFR therapies. Similarly, resistance to MET inhibition may be mediated through EGFR activation, or alternatively by increasing levels of MET amplification or acquisition of novel "gatekeeper" mutations. In order to optimize development of effective inhibitors of the MET/HGF pathway clinical trials must be enriched for patients with demonstrable MET-pathway dysregulation for which robustly standardized and validated assays are required.

Diffusion-weighted MRI and optimal b-value for characterization of liver lesions

BACKGROUND

Diffusion-weighted imaging (DWI) is commonly used to distinguish between benign and malignant liver lesions. However, different b-values are recommended.

PURPOSE

To determine the most suitable b-value in DWI for differentiation of benign and malignant liver lesions.

MATERIAL AND METHODS

A total of 124 lesions in 89 consecutive patients (43 men, 46 women; age, mean ± standard deviation, 58 ± 14 years) with a pathological or radiological diagnosis of malignant or benign focal liver lesions after magnetic resonance imaging (MRI) were included in this study. Routine abdominal MRI and DWI were performed using seven b-values (0, 50, 200, 400, 600, 800, 1000 s/mm(2)). Lesions were analyzed for benignity/malignity using apparent diffusion coefficient (ADC) values with 10 b-value combinations and by measuring the lesion/normal parenchyma ADC ratio.

RESULTS

Mean ADC values were significantly different between malignant and benign lesions for all b-value combinations (P=0.000). The best b-value combination was 0 and 800 (Az=0.935). Using lower b-values such as 0 and 50 together with higher b-values ≥ 600 s/mm(2) was beneficial (Az=0.928 and 0.927). Mean ADC values were approximately 13% (1-15%) higher in total when b=0 and b=50 s/mm(2) were included in multiple b-value combinations.

CONCLUSION

In DWI, we recommend the use of b-values of 0 and 800 s/mm(2) as two b-values, or b=0, 50, 600, 800, and 1000 s/mm(2) as multiple b-values for distinguishing between benign and malignant liver lesions. Mean ADC value is 13% higher in total by additional use of b=0 and b=50 s/mm(2) in multiple b-value combinations.

Hepatocellular cancer: the impact of obesity, type 2 diabetes and a multidisciplinary team

BACKGROUND & AIMS

Hepatocellular cancer (HCC) commonly complicates chronic liver disease and increases in incidence have been reported despite falling prevalences of viral hepatitis.

METHODS

Following the introduction of centralised specialist teams to manage patients with cancer in England, we characterised the demographics of patients with HCC referred to the Newcastle-upon-Tyne Hospitals NHS Foundation Trust between 2000 and 2010. Regional HCC mortality data was from Public Health England.

RESULTS

HCC related mortality in the region rose 1.8 fold in 10 years, from 2.0 to 3.7 per 100,000. 632 cases were reviewed centrally, with 2-3 fold increases in referrals of patients with associated hepatitis C, alcoholic liver disease or no chronic liver disease and a >10 fold increase in HCC associated with non-alcoholic fatty liver disease (NAFLD). By 2010 NAFLD accounted for 41/118 (34.8%) cases. Irrespective of associated etiologies, metabolic risk factors were present in 78/118 (66.1%) cases in 2010, associated with regional increases in obesity and diabetes. Median overall survival was just 10.7 months. Although patients with NAFLD associated HCC were older (71.3 yr vs. 67.1 yr; p<0.001) and their cancers less often detected by surveillance, their survival was similar to other etiologies. This was attributed to significantly higher incidental presentation (38.2%) and lower prevalence of cirrhosis (77.2%).

CONCLUSIONS

HCC related mortality is increasing, with typical patients being elderly with metabolic risk factors. The prognosis for most of the cases is poor, but older patients with co-morbidities can do well, managed, within a specialist multidisciplinary team if their cancer is detected pre-symptomatically.

microRNAs in liver disease: from diagnostics to therapeutics

There is a need to identify effective biomarkers for diagnosis, prognosis and prediction of treatment efficacy for many liver diseases such as hepatocellular cancer, and chronic viral hepatitis. The identification of disease-specific alterations in microRNA expression and the ability to detect microRNAs in the circulation provide the basis for identifying novel clinically effective treatments and biomarkers. Knowledge regarding miRNA in human liver disease may eventually lead to serum or tissue biomarkers with clinical utility. A selection of relevant studies is reviewed. There are major challenges that need to be addressed prior to clinical application such as the need for careful validation of diagnostic miRNA candidates in well described clinical cohorts, and technical issues such as quantitation and standardization of assays. The rapid progress in therapeutic interventions using miRNA based strategies for chronic hepatitis C and hepatocellular cancer provides optimism for novel approaches that will build on the existing and emerging knowledge regarding miRNA in liver diseases.

Getting it right: the impact of a continuing medical education program on hepatitis B knowledge of Australian primary care providers

Introduction:

In Australia, chronic hepatitis B (CHB) disproportionately affects migrants born in hepatitis B endemic countries, but its detection and management in high risk populations remains suboptimal. We piloted a primary care based program for CHB detection and management in an area of high disease prevalence in Sydney, Australia. Prior to its launch, all local general practitioners were invited to take part in a continuing medical education (CME) program on hepatitis B diagnosis and management.

Material and methods:

Preceding each CME activity, participants completed an anonymous survey recording demographic data and hepatitis B knowledge, confidence in CHB management, and preferred CME modalities. We compared knowledge scores of first-time and repeat attendees.

Results:

Most participants (75%) were males, spoke more than one language with their patients (91%), self-identified as Asian-Australians (91%), and had graduated over 20 years previously (69%). The majority (97%) knew what patient groups require CHB and hepatocellular cancer screening, but fewer (42%–75%) answered hepatitis B management and vaccination questions correctly. Knowledge scores were not significantly improved by seminar attendance and the provision of hepatitis B resources. At baseline, participants were fairly confident about their ability to screen for CHB, provide vaccinations, and manage CHB. This did not change with repeat attendances, and did not correlate with survey outcomes. Large group CMEs were the preferred learning modality.

Discussion:

Knowledge gaps in hepatitis B diagnosis and management translate into missed opportunities to screen for CHB, to vaccinate those susceptible, and to prevent disease complications. The results suggest that a range of innovative CME programs are required to update general practitioners on the modern management of CHB infection.

Tryptase serum levels in patients suffering from hepatocellular carcinoma undergoing intra-arterial chemoembolization: Possible predictive role of response to treatment

Tryptase is a serin protease stored in mast cell granules that has recently been found to be involved in tumor angiogenesis. Data from experimental tumor models have suggested that prior to the onset of angiogenesis mast cells were accumulated near tumor cells and were required for the macroscopic expansion and metastatic spread of primary tumor cells. Hepatocellular cancer (HCC) is a well-established, highly angiogenesis-dependent hypervascular tumor. The aim of this preliminary study was to assess tryptase serum levels in 30 HCC patients prior and subsequent to hepatic transarterial chemoembolization (TACE). In this study, patients with intermediate stage (B) HCC, according to the Barcelona Clinic Liver Cancer (BCLC) staging classification, were enrolled. Additional patient features were adequate liver functional reserve and A or B status, according to the Child-Pugh classification. Tryptase levels were measured using the UniCAP-Tryptase fluoroimmunoassay. TACE was performed by loading doxorubicin on microspheres. The mean ± standard deviation (SD) tryptase level pre-TACE was 7.74±3.62 μg/l, and post-TACE 4.67±2.79 μg/l. A statistically significant difference (P<0.001) was detected, using the Student's t-test, between pre- and post-TACE tryptase level concentrations. No correlations were found between tryptase levels and other important clinicopathological features of patients. This is the first preliminary study analyzing the potential significance of serum tryptase levels in HCC patients. The results demonstrated higher serum tryptase levels in HCC patients, suggesting tryptase release from HCC tissue. As expected, after TACE, serum tryptase levels were decreased. Therefore, we suggested that tryptase was a potential biomarker of response to TACE treatment in HCC patients.

Leptin and cancer: Pathogenesis and modulation

Leptin, a product of Ob gene from adipocytes regulates appetite, energy expenditure and body mass composition by decreasing orexigenic and increasing anorexigenic neuropeptide release from hypothalamus. Research over the past few years have suggested leptin/leptin receptor dysregulation to have a role in the development of a large variety of malignancies like breast ca, thyroid ca, endometrial ca and gastrointestinal malignancies, predominantly through JAK/STAT pathway which modulates PI3K/AKT3 signaling, ERK1/2 signaling, expression of antiapoptotic proteins (like XIAP), systemic inflammation (TNF-α, IL6), angiogenic factors (VEGF) and hypoxia inducible factor-1a (HIF-1a) expression. In this review, the current understanding of leptin's role in carcinogenesis has been elaborated. Also a few agents modulating leptin signaling to inhibit cancer cell growth has been described.

Phase 2 study of bevacizumab plus erlotinib in patients with advanced hepatocellular cancer

BACKGROUND

Epidermal growth factor receptor (EGFR) and vascular endothelial growth factor (VEGF) are rational targets for therapy in hepatocellular cancer (HCC).

METHODS

Patients with histologically proven HCC and not amenable to curative or liver directed therapy were included in this 2-stage phase 2 trial. Eligibility included an Eastern Cooperative Oncology Group (ECOG) performance status (PS) of 0 or 1 and Child's Pugh score of A or B, and 1 prior systemic therapy. Patients received erlotinib 150 mg daily and bevacizumab 10 mg/kg on days 1 and 15 every 28 days. Objective tumor response was the primary end point.

RESULTS

Twenty-seven patients with advanced HCC (median age, 60 years) were enrolled in this multi-institutional study. The proportion of patients with Child's A classification was 74%. One patient had a confirmed partial response and 11 (48%) achieved stable disease. Median time to disease progression was 3.0 months (95% confidence interval [CI], 1.8-7.1). Median survival time was 9.5 months (95% CI, 7.1-17.1). Grade 3 toxicities included rash, hypertension, fatigue, and diarrhea.

CONCLUSIONS

In this trial, erlotinib combined with bevacizumab had minimal activity in patients with advanced HCC based on objective response and progression-free survival. The role of targeting EGFR and VEGF in HCC needs further evaluation in molecularly selected patients.

Molecular hepatic carcinogenesis: impact of inflammation

Hepatocellular cancer (HCC) represents one of the most rapidly spreading cancers in the world. Most HCC develops in cirrhotic livers after prolonged inflammation, supporting the hypothesis that inflammation contributes to cancer development. Increasing evidence suggests that inflammatory cell recruitment and activation is an important contributor to promoting cancerous malformation in hepatocytes. Intracellular signaling pathways involved in classical inflammatory pathway activation can be altered in parenchymal cells, hepatocytes, in the liver to promote HCC development. Inflammation is triggered by pathogen-derived or endogenous danger-associated molecular patterns via pattern recognition receptors. Activation of the pattern recognition receptors triggers downstream signaling cascades to induce proinflammatory cytokine production, release of reactive oxygen species and modulate cellular responses. Many of these inflammatory mediators have adverse effects on DNA repair and induce DNA methylation, both of which are important elements in HCC development. This review summarizes the key points and discusses recent findings related to the role of inflammation in cancer and HCC development.

Positron emission tomography for staging and assessment of tumor response of hepatic malignancies

(18)F-fluorodeoxyglucose (FDG) positron emission tomography (PET) is a useful functional imaging method that complements conventional anatomic imaging modalities for screening patients with colorectal hepatic metastases and hepatocellular cancer to determine their suitability for interventional procedures. FDG PET is more sensitive in detecting colorectal cancer than hepatocellular cancer (~90% versus ~50%). The likelihood of detecting hepatic malignancy with FDG PET rapidly diminishes for lesions smaller than 1 cm. The greatest value of FDG PET in these patients is in excluding extrahepatic disease that might lead to early recurrence after interventional therapy. Promising results have been reported with FDG PET that may show residual (local) or recurrent disease before conventional imaging methods in patients receiving interventional therapy. For patients with colorectal hepatic metastases, many investigators believe that patients with PET evidence of recurrent hepatic disease should receive additional treatment even when there is no confirmatory evidence present on other methodologies. For patients with hepatocellular cancer no conclusions regarding the value of FDG PET for assessment of response to interventional therapy can be reached as there is almost no published data.

Transforming growth factor-β adaptor, β2-spectrin, modulates cyclin dependent kinase 4 to reduce development of hepatocellular cancer

Transforming growth factor beta (TGF-β) is an important regulator of cell growth, and loss of TGF-β signaling is a hallmark of carcinogenesis. The Smad3/4 adaptor protein β2-spectrin (β2SP) is emerging as a potent regulator of tumorigenesis through its ability to modulate the tumor suppressor function of TGF-β. However, to date the role of the TGF-β signaling pathway at specific stages of the development of hepatocellular carcinoma (HCC), particularly in relation to the activation of other oncogenic pathways, remains poorly delineated. Here we identify a mechanism by which β2SP, a crucial Smad3 adaptor, modulates cyclin dependent kinase 4 (CDK4), cell cycle progression, and suppression of HCC. Increased expression of β2SP inhibits phosphorylation of the retinoblastoma gene product (Rb) and markedly reduces CDK4 expression to a far greater extent than other CDKs and cyclins. Furthermore, suppression of CDK4 by β2SP efficiently restores Rb hypophosphorylation and cell cycle arrest in G(1) . We further demonstrate that β2SP interacts with CDK4 and Smad3 in a competitive and TGF-β-dependent manner. In addition, haploinsufficiency of cdk4 in β2sp(+/-) mice results in a dramatic decline in HCC formation compared to that observed in β2sp(+/-) mice.

CONCLUSION

β2SP deficiency leads to CDK4 activation and contributes to dysregulation of the cell cycle, cellular proliferation, oncogene overexpression, and the formation of HCCs. Our data highlight CDK4 as an attractive target for the pharmacologic inhibition of HCC and demonstrate the importance of β2sp(+/-) mice as a model of preclinical efficacy in the treatment of HCC.

Synergistic activity of histone deacetylase and proteasome inhibition against pancreatic and hepatocellular cancer cell lines

AIM

To determine the phenotypic effects of belinostat (bel) and bortezomib (bor) against pancreatic cancer (PC) and hepatocellular cancer (HCC) cell lines.

MATERIALS AND METHODS

Antiproliferative effects were assessed using a sulforhodamine B assay. Synergy was evaluated using the Chou and Talalay method. Apoptosis was measured by caspase-3/-7 activity and PARP cleavage. Downstream effector proteins were detected via immunoblotting. Quantitative nuclear magnetic resonance (NMR)-based metabolomics analysis was performed.

RESULTS

There were single-agent antiproliferative effects against PC and HCC cell lines; the combination of bel and bor (bel+bor) had a synergistic effect. There was up to a 45-fold induction of apoptosis over the control. Post-treatment cell death was associated with p21 up-regulation, more pronounced with treatment with bel+bor. Treatment with bel+bor enhanced hyperacetylation of histone H3 over single-agent bel. A metabolic signature was established for treatments with bor and bel+bor.

CONCLUSION

The combination of bel+bor displayed significant antiproliferative activity against PC and HCC cell lines, with exhibiting synergistic antiproliferative and proapoptotic patterns even at suboptimal single-agent doses.

Pegylated interferon alpha targets Wnt signaling by inducing nuclear export of β-catenin

BACKGROUND & AIMS

Pegylated-Interferon-α2a (peg-IFN), a first line therapy for Hepatitis C virus (HCV) patients, also impacts the recurrence of hepatocellular carcinoma (HCC). The activation of the Wnt pathway due to β-catenin gene mutations contributes to the development of a significant subset of HCC. Herein, we explored the effect of peg-IFN on Wnt/β-catenin signaling in vitro and in vivo.

METHODS

Multiple human hepatoma cell lines were treated with Peg-IFN to assess its effect on the Wnt pathway and the mechanisms involved. Transgenic (TG) mice expressing stable β-catenin mutant in the liver were exposed to diethylnitrosamine (DEN) and treated with peg-IFN.

RESULTS

In vitro, peg-IFN decreased the transcriptional activity of β-catenin/Tcf and did so independently of JAK/Stat signaling. Peg-IFN treatment led to increased mRNA and protein expression of RanBP3, a known β-catenin nuclear export factor, in all hepatoma cells. Co-precipitation studies showed an increased association between RanBP3 and β-catenin after peg-IFN treatment. The siRNA-mediated RanBP3 knockdown abrogated Peg-IFN-induced decrease in TOPFlash reporter activity. In vivo, Peg-IFN treatment led to increased nuclear RanBP3, decreased nuclear β-catenin and cyclin D1, and decreased cytoplasmic glutamine synthetase. Increased association of RanBP3 and β-catenin was also observed in vivo in response to Peg-IFN that led to decreased hepatocyte proliferation.

CONCLUSIONS

Peg-IFN inhibits β-catenin signaling through the up-regulation of RanBP3, which may be a contributory mechanism for the delayed HCC and improved survival in treated HCV patients. This observation might have chemo-preventive or chemo-therapeutic implications in tumor with aberrant Wnt pathway activation.

Imaging to optimize liver tumor ablation

Surgical resection remains the ideal treatment for hepatocellular carcinoma and metastasis to the liver. Many alternatives are available for treatment of nonsurgical candidates. Regardless of treatment, optimizing imaging in the pretreatment, treatment and post-treatment settings is critical in order to lower the rates of local tumor progression and maximize the effectiveness of treatment that may result in prolonged survival. This article summarizes some basic imaging techniques of primary and metastatic liver tumors with a focus on how to optimize their treatment with ablation.

Pretreatment assessment of hepatocellular carcinoma: expert consensus statement

Staging of hepatocellular carcinoma (HCC) is complex and relies on multiple factors including tumor extent and hepatic function. No single staging system is applicable to all patients with HCC. The staging of the American Joint Committee on Cancer / International Union for Cancer Control should be used to predict outcome following resection or liver transplantation. The Barcelona Clinic Liver Cancer scheme is appropriate in patients with advanced HCC not candidate for surgery. Dual phase computed tomography or magnetic resonance imaging can be used for pretreatment assessment of tumor extent but the accuracy of these methods remains poor to characterize < 1 cm lesions. Assessment of tumor response should not rely only on tumor size and new imaging methods are available to evaluate response to therapy in HCC patients. Liver volumetry is part of the preoperative assessment of patients with HCC candidate for resection as it reflects liver function. Preoperative portal vein embolization is indicated in patients with small future liver remnant (≤ 20% in normal liver; ≤ 40% in fibrotic or cirrhotic liver). Tumor size is not a contraindication to liver resection. Liver resection can be proposed in selected patients with multifocal HCC. Besides tumor extent, surgical resection of HCC may be performed in selected patients with chronic liver disease.

Nonoperative therapies for combined modality treatment of hepatocellular cancer: expert consensus statement

Although surgical resection and liver transplantation are the only treatment modalities that enable prolonged survival in patients with hepatocellular carcinoma (HCC), the majority of HCC patients presents with advanced disease and do not undergo resective or ablative therapy. Transarterial chemoembolization (TACE) is indicated in intermediate/advanced stage unresectable HCC even in the setting of portal vein involvement (excluding main portal vein). Sorafenib has been shown to improve survival of patients with advanced HCC in two controlled randomized trials. Yttrium 90 is a safe microembolization treatment that can be used as an alternative to TACE in patients with advanced liver only disease or in case of portal vein thrombosis. External beam radiation can be helpful to provide local control in selected unresectable HCC. These different treatment modalities may be combined in the treatment strategy of HCC and also used as a bridge to resection or liver transplantation. Patients should undergo formal multidisciplinary evaluation prior to initiating any such treatment in order to individualize the best available options.

Surgical treatment of hepatocellular carcinoma: expert consensus statement

As the number of effective treatment options has increased, the management of patients with hepatocellular carcinoma has become complex. The most appropriate therapy depends largely on the functional status of the underlying liver. In patients with advanced cirrhosis and tumor extent within the Milan criteria, liver transplantation is clearly the best option, as this therapy treats the cancer along with the underlying hepatic parenchymal disease. As the results of transplantation has become established in patients with limited disease, investigation has increasingly focused on downstaging patients with disease outside of Milan criteria and defining the upper limits of transplantable tumors. In patients with well preserved hepatic function, liver resection is the most appropriate and effective treatment. Hepatic resection is not as constrained by tumor extent and location to the same degree as transplantation and ablative therapies. Some patients who recur after resection may still be eligible for transplantation. Ablative therapies, particularly percutaneous radiofrequency ablation and transarterial chemoembolization have been used primarily to treat patients with low volume irresectable tumors. Whether ablation of small tumors provides long term disease control that is comparable to resection remains unclear.

Current use and potential role of bevacizumab in the treatment of gastrointestinal cancers

Angiogenesis is essential for cancer growth and metastasis. Vascular endothelial growth factor (VEGF) is a key modulator of angiogenesis. In addition, overexpression of VEGF is correlated with advanced disease and poor prognosis. Bevacizumab, a recombinant humanized anti-VEGF monoclonal antibody, is the first anti-angiogenic agent approved by Food and Drug Administration for use in treatment of human solid cancers. Although bevacizumab has received most attention for first-line treatment of advanced colorectal and nonsmall-cell lung cancer, there is a rapidly growing body of evidence for its efficacy in treatment of a number of other solid tumors. We present the current status and potential use of bevacizumab therapy in gastrointestinal cancers.

Targeting cancers in the gastrointestinal tract: role of capecitabine

Capecitabine is currently the only novel, orally home-administered fluorouracil prodrug. It offers patients more freedom from hospital visits and less inconvenience and complications associated with infusion devices. The drug has been extensively studied in large clinical trials in many solid tumors, including breast cancer, colorectal cancer, gastric cancer, and many others. Furthermore, the drug compares favorably with fluorouracil in patients with such cancers, with a safe toxicity profile, consisting mainly of gastrointestinal and dermatologic adverse effects. Whereas gastrointestinal events and hand-foot syndrome occur often with capecitabine, the tolerability profile is comparatively favorable. Prompt recognition of severe adverse effects is the key to successful management of capecitabine. Ongoing and future clinical trials will continue to examine, and likely expand, the role of capecitabine as a single agent and/or in combination with other anticancer agents for the treatment of gastrointestinal as well as other solid tumors, both in the advanced palliative and adjuvant settings. The author summarizes the current data on the role of capecitabine in the management of gastrointestinal cancers.

The current role of PET-CT in the characterization of hepatobiliary malignancies

BACKGROUND

Surgery has become heavily dependent on accurate imaging in the assessment and treatment of suspected or confirmed intra-abdominal malignancy. Positron emission tomography-computed tomography (PET-CT) fuses uptake of a radiotracer combined with CT images to assess both functional tissue activity and anatomical detail. Since its introduction it has offered new ways of treating gastrointestinal cancers.

METHODS

The review analyses the present literature regarding the use of PET-CT in the assessment, diagnosis, staging and treatment of hepatobiliary malignancies.

RESULTS

PET-CT is widely used in pre-operative tumours staging for colorectal liver metastases. There is convincing data that it may also be applicable for neuroendocrine tumours, assessment of indeterminate pancreas lesions and clinical drug trials. PET-CT is of limited value in hepatocellular cancers, although new techniques in dual-tracer PET-CT may change this.

CONCLUSION

Knowledge of the strengths and limitations of PET-CT is important for all surgeons managing cancer of the hepatobiliary system. More clinical data are required on PET-CT, particularly its effect on long-term survival in PET-CT-staged patients undergoing resection.